Evidence informed massage, encourages the integration of current research into our practices, this requires reviewing the scientific literature as it relates to a number of concepts that are held near and dear in the world of massage therapy. As healthcare professionals, I think that it is important that we continue to strive for explanations that are in line with the current scientific understanding of how the body works. So, I was surprised to find out that nearly three decades after the publication of The Trigger Point Manual by David Simons and Janet Travell, there are still many questions about myofascial triggerpoints and the role they play in myofascial pain syndrome, that remain to be answered. With the recent rise in popularity of Pain Science this is an excellent opportunity to look into these sore spots, and see what has changed.

Scientific research does not only change the way we assess and treat injuries, it also involves using precise terminology and clear definition when we communicate with patients and other healthcare professionals. When it comes to myofascial triggerpoints, there is a need to update the way we talk about myofascial pain syndrome and more specifically myofascial triggerpoints. This statement may make massage therapists uncomfortable, but this is actually an opportunity to advance our understanding of pain.

What does the current research say about myofascial triggerpoints?

A change in thought was sparked by a critical review published in the journal Rheumatology. This scientific article shines some much needed light on dogmatic view of myofascial triggerpoints, stating that past theories have been “flawed both in reasoning and in science”. Some massage therapists take this as a hit against the efficacy of trigger point therapy, which it is not. Instead this article, serves to deconstruct the known etiology of myofascial trigger points, by calling into question long held assumptions about these enigmatic sore spots.

“The etiology of these sore spots is still not well understood, but that does not deny the existence of the clinical phenomenon.”

So, what are those sore spots that we continue to work on?

Here we are in 2016, nearly thirty years after the publication of ‘The Big Red Triggerpoint Book’, and there is still no consensus on the etiology of these sore spots. Fortunately the journal Pm&r published a paper that serves to forward our understanding on the subject of myofascial triggerpoints. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective, is a narrative review that defines myofascial triggerpoints as “hard, discrete, palpable nodules in a taut band of skeletal muscle that may be spontaneously painful (i.e., active) or painful only on compression (i.e., latent).” Here we are provided a clear definition, but when it comes to the the question of what makes up a myofascial triggerpoint the author acknowledges that the etiology of these sore spots not well understood, and presents a number of alternative explanatory models for the clinical phenomenon that is known as a myofascial trigger point including: neurogenic inflammation, central sensitization, end-plate noise and fascial densifications.

Even though researchers are still unsure what tissues are involved and how these change in response to treatment, “myofascial trigger points” certainly describe a phenomenon — sore, stiff, aching spots. From my review of the literature myofascial triggerpoints seem to represent a physiologic change in normal muscle tissue. This seems to be a secondary response to local hypoxia or mechanical irritation of a hypersensitive peripheral nerve (referred peripheral nerve pain) leading to a drop in tissue pH that triggers the release of inflammatory mediators, known as “inflammatory soup”, this noxious environment then sensitizes local tissue, but since the the etiology of these sore spots is still not completely understood, we must remember this is still just a hypothesis, not a scientific theory.

Stepping Back: What is the big picture?

I think it is important that we strive for explanations that are in line with the current scientific understanding of how the body works. Myofascial triggerpoints describe an observable phenomenon, but there is still no consensus on the etiology of these sore spots, how the local tissues changes in response to treatment and what role they play in the generation and propagation of myofascial pain syndrome. What we call a myofascial triggerpoints may represent, neuroplastic changes of the peripheral or central nervous system, or it could be a physiologic dysfunction involving local soft tissue. We should acknowledge that there is still uncertainty on the subject and update the way we communicate with patients and other healthcare providers. However, the way I see it, this does not mean we need to abandon treatment approaches that provide patients with pain relief.

From a clinical perspective, bodies are dynamic and complex, this is why ascribing patient’s pain solely to myofascial triggerpoints or other tissue-driven pain problem is often an oversimplification of a very complex process. Whether we ‘correcting a local pathology’, ‘providing sensory input’ resulting in the descending modulation of pain, or a combination of both, many patients’ continue to benefit from triggerpoint therapy. So even if our explanations have changed, what hasn’t changed is that many aches and pains can at least be partially helped by a combination of: compressions, active release or muscle stripping.

“The explanations used in the past for this observable phenomenon seem to be flawed in reasoning, but I do not think there is a need to abandon treatment approaches that provide patients with pain relief.”

Richard Lebert is a registered massage therapist with a professional interest in sports injuries, he works at The Fowler Kennedy Sports Medicine Clinic at Western University. Richard was recognized by The RMTAO as the 2016 Massage Therapists of The Year for developing the RMT Education Project – an evidence based resource for massage therapists. Outside of the office Richard spends his free time with his wife and is always looking for new spots to explore with his kayak or on foot.

Brian FultonBrian Fulton is a Registered Massage Therapist that has been practicing in St. Catharines, Ontario since 1999. He is also an author and an educator. He conducts workplace health and wellness seminars, and was the health columnist for Dalhousie Peer magazine for over ten years. His book, The Placebo Effect in Manual Therapy- Improving Clinical Outcomes, printed by Handspring Publications, is available through Amazon.